Document KRvnkBJL9zKq88GG0L589bJDw

Form 45A. D. WILES CO.. Indianapolis W. C. Forms for All States STATE OF ILLINOIS INDUSTRIAL COMMISSION 160 No. LaSalle St., Chicago 1, UL EMPLOYER'S REPORT OF COMPENSABLE INJURY (Copy should be sent immediately to Insurance Carrier) Accident Number Employers must report to the Commission on Form 45 between the 15th and 25th of EACH MONTH all compensable injuries. In case of DEATH report IMMEDIATELY. EMPLOYER: i. n .^. A. mer,ican C- vantw.ld. . rr^p^ny 2 Doing business under the name of - toSflmi--CyiMW I d--Company SllCCflSSQf_tfl_MacG rBQQf_IjBld Address. Street and No ^00 W*tJ Sth Street--------------------------City -CHIcago 3. Address, Street and No- 4. Nature of Business:-- lead Chaw! cal--Manufacturer 5. Name of compensation insurance carrier: ,NJUR,EDKTMPLOm.rt Coburn 1. Name:. 2. Address, Street and No. 4149 Watt 21t Place _City_ Chicago 3. Sex:_______ Hfl I 5. Age:. 53 year* 4. Marital Status- Harried 6. Occupation..Be11_MI.L1_Operator 7. Average Weekly Earnings:- 143.20 mm___ Five8. No. of Children under 18 years of age:. INJURY: 1. Date of injury:. June 7, 1971 2. Hour:. 3. How did injury happen:. Lead Absorption with Pending Lead Intoxication 4. What was employee doing when accident occurred?----Operating Ball Mill. ------------------------------- (Describe briefly, such as loading truck, operating drill press, shoveling sand, etc.) 5. Name of machine, tool, substance, or object most closely connected with the accident: Ball Mill (Name the machine, tool, appliance, gas, liquid, etc., involved) 6. If machine or vehicle, what part of it?................................................. ......... ......................................................................................... (State if gears, pulley, point of operation, etc.) 7. Where: Street and Nn 4500 Wfl8t__1 5^h_St., City Chicago> State 1111 no 1 S 8. Describe injury (if specific loss, give date of loss) Lead Absorption with Pending Lead Intoxi cation 79. Length of disability (if undetermined give estimate) WCBkS______________________________________ COMPENSATION IN NON-FATAL CASES: 1. Is compensation being paid?------ MP................................................. ..................................................................................................... 2. To whom?..-------------------------------------------------------------------------------------------------- ---------------____ 3. Rate of compensation:------------------------------------------------- Date of First Payment: 4. Intervals of payment:---------------------------------------------------------------------------------------------------- ------------------------------------------- 5. Are medical and hospital services being furnished?______Yd___________________________________________________________ 6. By whom?____Clearing Industrial Clinic 1 American Cyanaml d Company COMPENSATION IN FATAL CASES: 1. Has compensation been paid?----------------------------------------- --------------------------------------------------------------------------------------------- 2. To whom?-----------------------------------------------------------------:............ ....... ,, _ 3. State relationship to deceased:------------------------------------------------------------ --------------------------------------------------------------- ; 4. Rate of compensation:------------------------------------------------- Date of First Payment: 5. Intervals of payment:-------------------------------------------------------------------------------------------------------------------------------------------------6. Length of disability prior to death:----------------------------------------------------------------------------- ------------ ------------------------------------7. Have funeral and burial expenses been paid ?__________________________________________________________________________ 8. By whom?_____ __ ___ 9. Date of this report:. 8/30/71----------------------------------10* Signed:-------------------------------------------R. I. 8U--------- 11. Position:. Manager/MacGregor Products___ Form 45- A. D. WILES CO., Indianapolis W. C. Forms for All States STATE OF ILLINOIS INDUSTRIAL COMMISSION 160 No. LaSalle St., Chicago 1, ILL. EMPLOYER S REPORT OF COMPENSABLE INJURY (Copy should be sent immediately to Insurance Carrier) Accident Number Employers must report to the Commission on Form 45 between the 15th and 25th of EACH MONTH all compensable injuries. In case of DEATH report IMMEDIATELY. EMPLOYER: 1. Nim" AMFRITAM OVfiNhMin POMP AM!*-------------------------------------------------------------------------------------------- 2. Doing burincsa under the nflTM American cyanamid Company Successor to MacHregor Lead 3. Address, Street and No,. 4500 West -15th Street-------------------------- City. Chicago-------- --------------------4. Nature of Bminr- Lead Chemical Manufacturer---------------------------------------------------------------- 5. Name of compensation insurance carrier:--------------------------------------------------- INJURED EMPLOYEE: 1. Name- Robert Cobur-g----------------------------------------------------------------- .^92. Address, Street and No.:---- ^^ --WQSt--21 t--P1 ------------------- __City Chicago 3 Sex. 1e______ _____________________________ 4. Marital Status. Married___________ 5. Age:years --------------------------- -- 6. Occupation-- Bali Mill--Ope rater 7. Average Weekly Earnings:--------- 1 ^3_2Q----------------------------------------------- 8. No. of Children under 18 years of age:--------F i ve------------------------------------- INJURY: 1. Date of injury:. December 21 1Q71 2. Hour:_____ 1 1 t 1 5 am 3. How did injury happen:------ Wh tic W311t i ng--in the arsa .of the north aLsv-ator, W was climbing ladder when a wrench dropped from his pocket and hit Robert Coburn on the head .____________________________ Lee 4. What was employee doing when accident occurred? Wa 1 k i ng--fr-FOm one area to anot-ber----------------- (Describe briefly, such as loading truck, operating drill press, shoveling sand, etc.) 5. Name of machine, tool, substance, or object most closely connected with the accident:A wrench (Name the machine, tool, appliance, gas, liquid, etc., involved) 6. If machine or vehicle, what part of it?_ (State if gears, pulley, point of operation, etc.) lr,7. Where: Street and No-- g-QQ. Vf;--1 5th Street-------- Ci`y--Ch i cogo State___ | ] ] 8. Describe injury (if specific loss, give date of loss)----Bump on----head 9. Length of disability (if undetermined give estimate) COMPENSATION IN NON-FATAL CASES: 1. Is compensation being paid?------"5---------------------- 2. To whom?------ --------------------------------------------------3. Rate of compensation:----------------------------------------4. Intervals of payment:------------------------------------------5. Are medical and hospital services being furnished?- 6. By whom? ____________________________________ COMPENSATION IN FATAL CASES: 1. Has compensation been paid?------------------------------- 2. To whom?---------------------------------------------------------3. State relationship to deceased:_---------------------------4. Rate of compensation:----------------------------------------5. Intervals of payment:---------------------- -------------------6. Length of disability prior to death:_______________ 7. Have funeral and burial expenses been paid?--------8. By whom?--------------------------------------------------------9. Date of this report:--------------------------------------------- Date of First Payment:. Date of First Payment:. 10. Signed:11. Position:_____________________ CY 0005345